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Brunn Strom
Brunn Strom
Brunn Strom
Enas Elsayed
Brunnstrom Approach
Learning Objectives:
By the end of this lab, the student will be able to:
1. Demonstrate different reflexes including stimulus and muscle
tone response.
2. Demonstrate how to evoke associated reactions in both upper
and lower extremities.
3. Perform sensory evaluation according to Brunnstrom technique.
4. Describe the characteristics of each motor stage.
5. Apply speed test.
6. Evaluate practically basic limb synergies.
7. Describe practically different exercises based on treatment
principles of Brunnstrom.
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Dr. Enas Elsayed
Evaluation:
1. Tonic reflexes (STNR, ATNR, tonic labyrinthine "supine & prone",
tonic lumbar reflex, tonic thumb reflex, +ve supporting reaction, -ve
local static reaction, tonic thumb reflex and flexor withdrawal reflex).
Influence of reflexes:
Varying degrees of influence of the postural reflexes may be noted,
and are often associated with spasticity and synergy involvement.
Symmetric Tonic Neck Reflex (STNR):
Flexion of the neck results in flexion of the arms and extension of
the legs; extension of the neck results in extension of the arms and flexion
of the legs.
Asymmetric Tonic Neck Reflex (ATNR):
Head rotation to the left causes extension of left arm and leg and
flexion of right arm and leg; head rotation to the right causes extension of
right arm and leg and flexion of left arm and leg.
Tonic Labyrinthine Reflex (TLR):
Prone lying position facilitates flexion; the supine position
facilitates extension. The reflex can also be thought of as inhibition of
extensor tone in the prone position.
Tonic Lumbar Reflex:
This is initiated by a change in the position of the upper trunk with
respect to the pelvis. Rotation of the trunk to the right results in flexion of
the right upper extremity and extension of the right lower extremity;
rotation of the trunk to the left results in extension of the right upper
extremity and flexion of the right lower extremity.
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Dr. Enas Elsayed
2. Associated reactions:
Associated reactions are automatic responses of the involved limb
resulting from action occurring in some other part of the body, either by
voluntary or reflex stimulation (e.g., resistance or ATNR). They are
commonly elicited when some degree of spasticity is present and are
infrequently seen in a limb exhibiting minimal muscle tone. Generally
speaking, although not true in every case, associated reactions elicit the
same direction of movement (i.e., flexion evokes flexion) and the
opposite direction (i.e., flexion evokes extension) in the lower extremity.
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Dr. Enas Elsayed
Souques’ Phenomenon:
Elevation of the affected arm above the horizontal evokes an
extension and abduction response of the fingers.
Souques’ Phenomenon
Raimiste’s Phenomenon:
Resistance applied to abduction or adduction of the nonaffected lower
extremity evokes a similar reaction in the affected limb.
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Dr. Enas Elsayed
Joint sense: With the patient seated and is blindfolded; the affected upper
limb is supported by the examiner and moved to different positions
asking the patient to perform identical position with the unaffected
extremity.
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Dr. Enas Elsayed
Placing the hand behind the body, alternative pronation- supination with
the elbow at 90° flexion and elevation of the arm to a forward horizontal
position).
Stage 5: There is relative independence of the basic limb synergies.
Spasticity is wanning, and movements can be performed as arm raising to
a side horizantal position, alternative pronation- supination with the
elbow extended and bringing hand over the head.
Stage 6: There are isolated joint movements.
5- Speed test
It can be used to assess spasticity during anyone of the recovery stages,
provided that the patient has sufficient active ROM. The patient is seated
on a chair without armrest leaning against chair back and keeping the
head erect. The two movements studied are: (1) The hand is moved from
lap to chin, requiring complete range of elbow flexion.
(2) The hand is moved from lap to opposite knee, requiring full range of
elbow extension.
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Dr. Enas Elsayed
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Dr. Enas Elsayed
Treatment principles:
(1) When no motion exists, movement is facilitated using reflexes, asso-
ciated reactions, proprioceptive facilitation, and/or exteroceptive
facilitation to develop muscle tension in preparation for voluntary
movement.
(2) The responses of the patient from such facilitation combine with the
patient's voluntary effort to produces semivoluntary movement.
(3) Proprioceptive and exteroceptive stimuli assist in eliciting the
synergies.
(4) When voluntary effort appears:
a) The patient is asked to hold (isometric) the contraction.
b) If successful, he is asked for an eccentric (controlled lengthening)
contraction.
c) Finally, a concentric (shortening) contraction.
d) Reversal of the movement between the agonist and antagonist.
(5) Facilitation is reduced or dropped out as quickly as the patient shows
voluntary control (primitive reflexes & associated reactions).
(6) Correct movement is repeated.
(7) Practice in the form of ADL.
N.B. All pathological and physiological methods of facilitation are
indicated during the first three motor stages. While, only the
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Dr. Enas Elsayed
Example of exercise:
Trunk balance in sitting
The patient is asked to assume sitting position, lifting the affected upper
extremity by the unaffected one and do actively trunk movements in all
directions.
Trunk control
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1. Pedretti L and Early M: Occupational Therapy: Practice skills for physical
dysfunction. 5th ed., Mosby, London, 2001.